The German guidelines for airway management aim to optimize the care of patients undergoing anesthesia or intensive care. The preanesthesia evaluation is an important component for detection of anatomical and physiological indications for difficult mask ventilation and intubation. If predictors for a difficult or impossible mask ventilation and/or endotracheal intubation are present the airway should be secured while maintaining spontaneous breathing. In an unexpectedly difficult intubation, attempts to secure the airway should be limited to two with each method used. A video laryngoscope is recommended after an unsuccessful direct laryngoscopy. Therefore, a video laryngoscope should be available at every anesthesiology workspace throughout the hospital. Securing the airway should primarily be performed with a video laryngoscope in critically ill patients and patients at risk of pulmonary aspiration. Experienced personnel should perform or supervise airway management in the intensive care unit.

Die Leitlinie Atemwegsmanagement soll zur optimalen Versorgung der anästhesiologisch und intensivmedizinisch betreuten Patient:innen beitragen. Die präanästhesiologische Evaluation ist ein wichtiger Baustein zur Detektion anatomischer und physiologischer Hinweise für eine erschwerte Maskenbeatmung und Intubation. Wenn Prädiktoren für eine schwierige oder unmögliche Maskenbeatmung und/oder endotracheale Intubation vorliegen, soll die Atemwegssicherung unter Erhalt der Spontanatmung erfolgen. Besteht ein unerwartet schwieriger Atemweg, wird nach erfolgloser direkter Laryngoskopie die Verwendung eines Videolaryngoskops empfohlen, weshalb ein Videolaryngoskop an jedem anästhesiologischen Arbeitsplatz verfügbar sein soll. Bei aspirationsgefährdeten und kritisch kranken Patient:innen soll primär die Sicherung der Atemwege mit einem Videolaryngoskop erfolgen. Die Durchführung bzw. Supervision von Atemwegssicherungen auf der Intensivstation obliegt im Atemwegsmanagement erfahrenem Personal.

ZusammenfassungIm Rahmen der präklinischen Notfallintubation ist die Erfolgsrate videolaryngoskopischer Systeme mit unterschiedlichen Spateltypen im Vergleich nicht hinreichend untersucht. In der vorliegenden prospektiven, randomisierten, multizentrischen Untersuchung wurden die 3 kommerziell erhältlichen Videolaryngoskope A. P. Advance, C-MAC PM und King Vision an 168 Patienten mit präklinischer Notfallintubation hinsichtlich Gesamt- und Ersterfolgsrate der Intubation sowie Parameter der Handhabung untersucht. Alle 3 Videolaryngoskope ermöglichten eine vergleichbar gute Sicht auf die Glottisstrukturen, dennoch unterschied sich der Intubationserfolg relevant. Die Intubation war mit dem King Vision mit Führungskanalspatel am schwierigsten (Gesamterfolgsrate bei A. P. Advance, C-MAC PM und King Vision: 96, 97 bzw. 61% (p < 0,001; Ersterfolgsrate: 86, 85 bzw. 48% (p < 0,001). In 5 Fällen beim A. P. Advance und in 4 Fällen beim C-MAC PM war eine Intubation unter direkt laryngoskopischer Sicht mit dem jeweiligen Gerät notwendig. Beim King Vision wurde in 21 Fällen auf ein alternatives Gerät gewechselt. Dementsprechend sollten gerätespezifische Besonderheiten und Limitationen einzelner Videolaryngoskope bei der Ausbildung berücksichtigt werden.

BACKGROUND: Videolaryngoscopy is a valuable technique for endotracheal intubation. When used in the perioperative period, different videolaryngoscopes vary both in terms of technical use and intubation success rates. However, in the prehospital environment, the relative performance of different videolaryngoscopic systems is less well studied. METHODS: We conducted this prospective, randomized, multicenter study at 4 German prehospital emergency medicine centers. One hundred sixty-eight adult patients requiring prehospital emergency intubation were treated by an emergency physician and randomized to 1 of 3 portable videolaryngoscopes (A.P. Advance, C-MAC PM, and channeled blade KingVision) with different blade types. The primary outcome variable was overall intubation success and secondary outcomes included first-attempt intubation success, glottis visualization, and difficulty with handling the devices. P values for pairwise comparisons are corrected by the Bonferroni method for 3 tests ( P [BF]). All presented P values are adjusted for center. RESULTS: Glottis visualization was comparable with all 3 devices. Overall intubation success for A.P. Advance, C-MAC, and KingVision was 96%, 97%, and 61%, respectively (overall: P < .001, A.P. Advance versus C-MAC: odds ratio [OR], 0.97, 95% confidence interval [CI], 0.13–7.42, P [BF] > 0.99; A.P. Advance versus KingVision: OR, 0.043, 95% CI, 0.0088–0.21, P [BF] < 0.001; C-MAC versus KingVision: OR, 0.043, 95% CI, 0.0088–0.21, P [BF] < 0.001). Intubation success on the first attempt with A.P. Advance, C-MAC, and KingVision was 86%, 85%, and 48%, respectively (overall: P < .001, A.P. Advance versus C-MAC: OR, 0.89, 95% CI, 0.31–2.53, P [BF] > 0.99; A.P. Advance versus KingVision: OR, 0.24, 95% CI, 0.055–0.38, P [BF] = 0.0054; C-MAC versus KingVision: OR, 0.21, 95% CI, 0.043–.34, P [BF] < 0.003). Direct laryngoscopy for successful intubation with the videolaryngoscopic device was necessary with the A.P. Advance in 5 patients, and with the C-MAC in 4 patients. In the KingVision group, 21 patients were intubated with an alternative device. CONCLUSIONS: During prehospital emergency endotracheal intubation performed by emergency physicians, success rates of 3 commercially available videolaryngoscopes A.P. Advance, C-MAC PM, and KingVision varied markedly. We also found that although any of the videolaryngoscopes provided an adequate view, actual intubation was more difficult with the channeled blade KingVision.

Sicherung und Kontrolle der Atemwege bei Notfallpatienten gehören zu den zentralen Anforderungen an eine suffiziente präklinische Therapie. Neben patientenbezogenen anatomischen und funktionellen Problemen sind Schwierigkeiten zu bedenken, die einerseits zusätzlich im Rahmen eines akuten Notfalls, andererseits aber auch durch ungünstige räumliche, logistische und personelle Gegebenheiten auftreten können. Ein Misserfolg bei der Sicherung der Atemwege kann innerhalb kürzester Zeit die Morbidität und Letalität bei diesen Patienten deutlich erhöhen.

The use of direct laryngoscopy for endotracheal intubation is one of the key skills of anaesthesiologists and every physician involved in airway management. Direct laryngoscopy confers the known advantages of familiarity, direct glottic visualisation, cost effectiveness, equipment availability, and a steep learning curve. However, the prevalence of insufficient views of the glottis is persistent. Therefore, alternative intubation techniques should be available in such a crucial situation, including indirect laryngoscopic techniques such as videolaryngoscopy. Current videolaryngoscopes play an important role in the management of an unexpected difficult airway. Additionally, the use of a videolaryngoscope may be considered in a predicted difficult airway, if mask ventilation and oxygenation can be warranted. However, it is important to know that today videolaryngoscopes do not build a homogeneous class; moreover, they differ in design, technical configuration, monitor type and, most importantly, in blade type, so that the user has to become familiar with each device before they are used in an emergency situation. Therefore, the greatest benefit from videolaryngoscopy may be obtained, if it is used routinely in elective cases to become familiar with the device outside of a difficult intubation situation. In this case, videolaryngoscopy has the potential to save time and decrease-patient morbidity. This review addresses actual videolaryngoscopy techniques and their use in both clinical and pre-hospital airway management scenarios.

Ischemic or volatile anesthetic preconditioning is defined as tissue protection from impending ischemic cell damage by repetitive short periods of tissue exposure to ischemia or volatile anesthetics. Objective of this study was to elucidate, if ischemic preconditioning and pharmacological preconditioning with sevoflurane have effects on muscle tissue oxygen saturation in patients undergoing surgical revascularization of the lower limb.

The C-MAC video laryngoscope substantially reduced poor glottic views and increased intubation success in ICU patients with at least one predictor for difficult intubation. However, all video-assisted and optical intubation devices have different view angles, thus producing different images with particular distortion, and even experts in 'old-fashioned' airway management need a substantial level of training with a certain device before using it safely and successfully in critical situations and patients. Video laryngoscopes, regardless of a particular brand or device, cannot be used intuitively - they require expert skills and routines to be turned into a life-saving airway management tool.

Background In this preliminary prospective observational study at four physician-led air rescue centres, the efficacy of the C-MAC (Karl Storz, Tuttlingen, Germany), a new portable videolaryngoscope, was evaluated during prehospital emergency endotracheal intubations.Methods 80 consecutive patients requiring prehospital emergency intubation, treated by a physician introduced in the use of the C-MAC were enrolled in this study.Results Indication for prehospital intubation was trauma in 45 cases (including maxillo-facial trauma in 10 cases), cardiopulmonary resuscitation in 14 cases, and unconsciousness of neurological aetiology and cardiogenic dyspnoea in 21 cases. Forty-nine patients were intubated with a C-MAC blade size 3, and 31 with a C-MAC blade size 4. Median time to successful intubation was 20 (min-max: 5-300) seconds; 63 patients were intubated on the first attempt, 13 on the second and four after more than two attempts. A Cormack-Lehane class 1 view of the glottis was seen in 46 patients, class 2a view in 21, class 2b in eight, class 3 in three and class 4 in two. Six patients could not be intubated with the videolaryngoscopic view, but were successfully intubated at the same attempt using the C-MAC with the direct laryngoscopic view.Conclusion The C-MAC videolaryngoscope was suitable for prehospital emergency endotracheal intubations with complicated airway conditions, such as maxillo-facial trauma. The option to perform direct laryngoscopy and videolaryngoscopy with the same device appears to be exceptionally important in the prehospital setting.

Pentax AWS. We also agree with comments from another letter by Xue et al. that a good view with videolaryngoscopy does not necessarily imply easy intubation conditions; we have addressed intubation difficulties because of the greater curvature of some videolaryngoscopic blades in the prehospital setting, and assume that it has to be used by those with experience. However, as we also described, the advantage of the curved D-BLADE is that it may be used with minimal delay with the existing C-MAC system, which provides a Macintosh videolaryngoscope with possibilities for both conventional direct laryngoscopy and videolaryngoscopy with a lesser curved blade. All patient data provided in the manuscript show best achievable glottic view; this resulted in a C-L grades 1 and 2a view in all 15 routine cases. However, in the 20 rescue cases, glottic view with conventional laryngoscopy could not be further improved. At this point, when an additional airway tool was required to facilitate tracheal intubation, the conventional attempt was defined as failed. We agree that an experienced anesthesiologist may successfully intubate the trachea despite a C-L grade 3 or 4 view in most cases ( 90%), using a bougie, McCoy blade, or a blind technique; however, in the remaining 10%, intubation is more difficult and may result in critical situations with the necessity of a different airway device. In contrast, despite the need for more than 1 attempt in 6 of 20 patients, every patient’s trachea was successfully intubated in the present study. Because our article is a technical communication describing the use of the D-BLADE for the first time, it lacks a randomized comparison with other (video-)laryngoscopes; this should be accomplished in the near future. In summary, our results suggest that the d-blade (as part of the C-MAC system) may allow a stepwise approach from direct C-MAC laryngoscopy to indirect videolaryngoscopy with the C-MAC, and finally to videolaryngoscopy with the curved C-MAC d-blade, given that it is used by an experienced and well-trained operator.

BACKGROUND:The C-MAC® (Karl Storz, Tuttlingen, Germany) has recently been introduced as a new device for videolaryngoscopy guided intubation. The purpose of the present study was to compare for the first time the C-MAC with conventional direct laryngoscopy in 150 patients during routine induction of anaesthesia.METHODS:After approval of the institutional review board and written informed consent, 150 patients (ASA I-III) with general anaesthesia were enrolled. Computer-based open crossover randomisation was used to determine the sequence of the three laryngoscopies: Conventional direct laryngoscopy (HEINE Macintosh classic, Herrsching, Germany; blade sizes 3 or 4; DL group), C-MAC size 3 (C-MAC3 group) and C-MAC size 4 (C-MAC4 group) videolaryngoscopy, respectively. After 50 patients, laryngoscopy technique in the C-MAC4 group was changed to the straight blade technique described by Miller (C-MAC4/SBT).RESULTS:Including all 150 patients (70 male, aged (median [range]) 53 [20-82] years, 80 [48-179] kg), there was no difference of glottic view between DL, C-MAC3, C-MAC4, and C-MAC4/SBT groups; however, worst glottic view (C/L 4) was only seen with DL, but not with C-MAC videolaryngoscopy. In the subgroup of patients that had suboptimal glottic view with DL (C/L≥2a; n = 24), glottic view was improved in the C-MAC4/SBT group; C/L class improved by three classes in 5 patients, by two classes in 2 patients, by one class in 8 patients, remained unchanged in 8 patients, or decreased by two classes in 1 patient. The median (range) time taken for tracheal intubation in the DL, C-MAC3, C-MAC4 and C-MAC4/SBT groups was 8 sec (2-91 sec; n = 44), 10 sec (2-60 sec; n = 37), 8 sec (5-80 sec; n = 18) and 12 sec (2-70 sec; n = 51), respectively.CONCLUSIONS:Combining the benefits of conventional direct laryngoscopy and videolaryngoscopy in one device, the C-MAC may serve as a standard intubation device for both routine airway management and educational purposes. However, in patients with suboptimal glottic view (C/L≥2a), the C-MAC size 4 with straight blade technique may reduce the number of C/L 3 or C/L 4 views, and therefore facilitate intubation. Further studies on patients with difficult airway should be performed to confirm these findings.

Die endotracheale Intubation stellt innerklinisch den sogenannten "Goldstandard" zur Sicherung der Atemwege dar. Lassen sich Probleme bei der Intubation durch konventionelle Maßnahmen nicht bewältigen, oder ist eine schwierige Intubation a priori zu erwarten, ist der Einsatz videoassistierter Verfahren zu bevorzugen. Diese ermöglichen eine indirekte Sicht auf die laryngealen Strukturen, das erfasste Bild wird per fiberoptischer oder Kamera-Chip-Technik auf einen Monitor geleitet. Bei erwartet schwieriger Intubation stellt die endoskopisch geführte Wachintubation mit einer flexiblen Fiberoptik immer noch die Methode der Wahl dar. Unter der Maßgabe, dass eine sichere Oxygenierung über Maskenbeatmung oder Einsatz einer supraglottischen Beatmungshilfe zu gewährleisten ist, können alternativ auch ein Intubationsendoskop oder ein Videolaryngoskop eingesetzt werden. Bei Beherrschung des Algorithmus für den unerwartet schwierigen Atemweg können letztgenannte Hilfsmittel auch als Notfallalternative zum Einsatz kommen.

Endotracheal intubation remains the "goldstandard" in airway management. If with use of conventional techniques intubation of the patient fails, or if an anticipated difficult airway is present, video-assisted techniques may help to increase intubation success. Video-assisted techniques give the possibility to indirectly visualise the laryngeal structures with fibreoptical or camerachip-technique, and to display the videopicture on an external or integrated monitor. For the anticipated difficult airway, awake flexible fibreoptical intubation still is the first choice. However, if Oxygenation and Ventilation can be established with bag-mask ventilation or supraglottic airways, the use of an endoscopic optical stylet or a videolaryngoscope may be alternatives. If the algorithm for the unanticipated difficult airway can be safely administered, the latter techniques may also be used as emergency intubation devices.

We studied the efficacy of the C-MAC (R) (Karl Storz, Tuttlingen, Germany), a new portable videolaryngoscope, in 60 patients during routine induction of anesthesia. It was possible to insert the blade (Size 3) of the C-MAC and to get a view of the glottis on the first attempt in all patients. Tracheal intubation also was successful in all 60 patients; 52 patients were intubated on the first attempt, 6 on the second, and 2 on the third. In 8 patients (13%), a gum elastic bougie guide was required. A Cormack-Lehane Class I view of the glottis was seen in 30 patients without external manipulation and in 45 with external manipulation, Class 2a view in 22 without and 12 with, Class 2b in 2 without, and Class 3 in 2 without manipulation. The median time taken for tracheal intubation was 16 s (range, 6-58 s). In addition, we describe Our experience with 3 patients in whom we had unexpected difficulty with direct laryngoscopy with a conventional Macintosh laryngoscope (Cormack-Lehane Class 3, 4, and 4, respectively). These patients' airways were Successfully managed on the first attempt when using the C-MAC Size 4 blade (improvement to Cormack-Lehane Class 1, 2a, and 2b, respectively) in a modified manner by Uploading the epiglottis, which is known as "straight blade technique." (Anesth Analg 2010;110:473-7)

Background and objective Analogue disposable devices of the laryngeal tube S II (LTS II) and the Fastrach laryngeal intubation mask (ILMA, Fastrach), namely the laryngeal tube disposable (LTS-D) and the Fastrach laryngeal intubation mask disposable (Fastrach-D), have recently been introduced. The purpose of this study was to compare each reusable device with the corresponding disposable one, during routine surgery. Methods After informed consent, 120 American Society of Anesthesiologists I–III patients scheduled for routine minor surgery were randomly allocated to the LTS II (n = 30), the LTS-D (n = 30), the Fastrach (n = 30) and the Fastrach-D (n = 30) groups, respectively. Overall insertion success rates, time to first sufficient ventilation (Vet≥ 200 ml), resulting airway leak pressures (ALPs), subjective assessment of handling as well as patient comfort were determined. Results Insertion success rates of the LTS II, LTS-D, Fastrach and Fastrach-D were 30/30, 29/30, 30/30 and 30/30, respectively. Time to successful insertion in the LTS II vs. the LTS-D group, as well as in the Fastrach vs. the Fastrach-D group, showed significant differences [median (min − max) s: 38 (13–187), 23 (9–108), P < 0,05; 27.5 (6–110), 16 (8–82), P < 0.05]. The highest ALP could be observed in the LTS-D group [median (min − max): 40 (16–40), P < 0.001 vs. all other devices] and the lowest ALP in the Fastrach-D group [median (min − max): 24.5 (12–40)]. ALP did not differ significantly in any group during variation of cuff volume by ±20 ml. Subjective assessment of handling was significantly (P < 0.001) better in the LTS-D group than in the LTS II, Fastrach and Fastrach-D groups. Conclusion LTS II, LTS-D, Fastrach and Fastrach-D were all suitable for routine airway management. The LTS-D showed the best properties in terms of airway sealing and handling.

Background: The aim of this porcine haemorrhagic shock model was to investigate the changes of bispectral index (BIS) after slow and fast recovery of cerebral perfusion, and its correlation with plasma propofol concentrations.Methods: After Animal Investigational Committee approval, 16 pigs during propofol anaesthesia underwent a liver trauma with severe hypotension, and were randomly assigned to receive therapy for either slow recovery (fluid resuscitation; slow group; n =8) or fast recovery of cerebral perfusion (vasopressor combined with hypertonic-saline-starch; fast group; n = 8), respectively. Cerebral perfusion pressure (CPP = MAP - ICP), cerebral tissue oxygenation index (TOI). BIS, and plasma concentrations of propofol and haemoglobin were measured at baseline (Pre-shock), haemodynamic decompensation (Shock), and 5 (Therapy) and 30 min (End) after therapy, respectively.Results: CPP, TOI, and BIS decreased significantly during shock (pre-shock vs. shock, fast: CPP: 65 +/- 14 vs. 15 +/- 4 mm Hg; TOI: 64 +/- 6 vs. 47 +/- 7%; BIS 60 +/- 5 vs. 9 +/- 10; show: CPP: 60 +/- 12 vs. 13 +/- 7 mm Hg; TOI: 68 +/- 7 vs. 49 +/- 7%; BIS 63 +/- 5 vs. 13 +/- 12; P < 0.05). In the fast group, CPP, TOI, and BIS increased after therapy compared to the slow group (Therapy, fast: CPP: 47 +/- 15 mm Hg, TOI: 61 +/- 7%, BIS: 47 +/- 21; slow: CPP: 18 +/- 9 mill Hg, TOI: 51 +/- 5%, BIS: 21 +/- 19; P < 0.05). Propofol and haemoglobin concentrations were comparable between groups throughout the resuscitation phase.Conclusions: In a haemorrhagic shock scenario, therapies with different impact on cerebral perfusion resulted in differing changes of BIS values, while plasma propofol and haemoglobin concentrations were comparable during the resuscitation phase; this suggests that BIS may also have reflected changes of cerebral perfusion. (C) 2010 Elsevier Ireland Ltd. All rights reserved.

In the present preliminary study we evaluated the C-MAC® D-Blade (Karl Storz, Tuttlingen, Germany), a new videolaryngoscopic C-MAC blade for difficult intubation, during both routine and difficult intubations. First, both the conventional direct laryngoscopy and the D-Blade were used in 15 consecutive patients with normal airways during routine induction of anesthesia. Second, the D-Blade was used as a rescue device in 20 of 300 (6.7%) consecutive patients, when conventional direct laryngoscopy failed. In the 15 patients during routine induction of anesthesia, with direct laryngoscopy, a Cormack-Lehane (C/L) grade 1 and grade 2a view was seen in 7 and 8 patients, respectively. It was possible to insert the D-Blade and to get a video view of the glottis on the first attempt in all patients; with the D-Blade, all 15 patients had a C/L 1 view. The time to successful intubation with the D-Blade was 15 (8-26) seconds (median (range)). In the 20 patients, in whom unexpected difficulty with direct laryngoscopy was observed, C/L grades 3 and 4 were present in 15 and 5 patients, respectively. With the use of the D-Blade, indirect C/L video view improved to C/L class 1 in 15 patients, and to 2a in 5 patients, respectively. The time from touching the laryngoscope to optimal laryngoscopic view was 11 (5-45) seconds and for successful intubation 17 (3-80) seconds. In all 35 patients, with the D-Blade no direct view of the glottis was possible and subsequently a semiflexible tube guide was required.